Tatalaksana dan Prognosis Tumor

periampullar

Terapi Pembedahan

Prosedur Whipple (Pancreaticoduodenectomy)

Mortalitas rendah di pusat kesehatan besar (<5%)

Survival rate terbaik (>50% 5-year)

Morbiditas tinggi (25-65%)

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

GUT Online.Guidelines for the management of patients with pancreatic cancer

periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Komplikasi prosedur whipple

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Prognosis terapi whipple

Faktor

Ada/tdk nya Nodus limfatikus yg terlibat

Penyebaran lokal organ2 sekitar (cth pankreas)

Grade tumnor/ diffrensiasi

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Eksisi Transduodenal (TDE)

Pertama kali dilakukan tahun 1898 oleh William

Halsted

Morbiditas lebih rendah (5-20%)

Lebih jrg berhasil (rekurensi, survival)

Hasil:

Belum ada studi dgn kualitas yg baik

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Pembedahan Radikal VS Lokal

Pertimbangan:

Stage tumor (T1,T2)

Kondisi Pasien

Indikasi TDE:

Adenoma dgn high-grade dysplasia

Villous atau tubullovillous adenoma

Low-grade. Stage tumor tanpa tingkat komorbiditas

yg tinggi.

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Faktor Prognosis TDE:

Penyebaran LN

Mudah/tdknya Operasi berjalan

Elevasi dr bilirubin

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Pre-oprative Endoscopic Stenting

Pertimbangan pre-reseksi:

Menurunkan morbiditas (kontroversial)

Pada kasus prosedur operasi hrs diundur >10 hr

GUT Online.Guidelines for the management of patients with pancreatic cancer

periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Terapi Endoskopik

Snare Resection

Laser Ablation

Photodynamic irradiation

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Eksisi Endoskopik

Kriteria

Adenomas <4 cm

Tdk ada striktur atau ekstenski ke ductal

Tdk ada ulser

Hasil dari biopsi ≥6x menunjukkan masa Benign

Tdk ada mortalitas, ttp ada kenaikan morbiditas

(10-27%)

Pendarahan

Pankreatitis

Varibel Rekurensi (5-25%)

Cameron J.L., Cameron A.M.. Current Surgical Therapy. 10th ed. Philadelphia. Elsevier;

2011

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Padolfi M, et al.. Endoscopic Treatment of Ampullary Adenomas. J Pancreas

(Online).2008;9(1):1-8

Flow Chart

Terapi Adjuvant

Kemoterapi (5-FluoroUracil)

[+doxirubicin+mitomycin C]

+/- XRT (45 Gy)

GUT Online.Guidelines for the management of patients with pancreatic cancer

periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Terapi Neoadjuvant

Radioterapi pre- dan post- op.

Improvement pd kontrol locoregional, ttp belum

ada perbaikan survival

Masih dlm masa penelitian

GUT Online.Guidelines for the management of patients with pancreatic cancer

periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026

Kemoterapi pd non-resectable

localised, metastatic , atau rekuren

Mestastasis survival rate 3-6bln, tergantung dr

luas penyebaran.

5-FU dan Mitomycin C terbaik

Gemcitabine digunakan pd adenocarcinoma

GUT Online.Guidelines for the management of patients with pancreatic cancer

periampullary and ampullary carcinomas. Gut.2005;54(V):1-16

Sohn T.A., Yeo C.J.. Pancreatic and Periampullary Carcinoma (Nonendocrine). In:

Zuidema G.D., Yeo C.J. (eds.)Shackelford's Surgery of the Alimentary Tract. 5th ed.

United States of America: W.B.Saunders; 2002. p5.5002-5026